Name:

Phone Number:

Your Email Address: :

Address:

City:

State: Zip Code:

Course Name:

Course Dates:

Agency Affliated: Yes No

Agency Affiliation (if applicable):

Contact Name:

Agency Address:

Agency City:

Agency State: Agency Zip Code:

Agency Email Address:

Agency Phone Number:

Agency Fax:

Agencies Only:  If billing address is different than above, please list contact name and mailing address

Billing Contact Name:

Agency Billing Address:

Agency Billing City:

Agency Billing State: Agency Billing Zip Code:

Comments:

Please be advised that this is an intent to attend course only.  You will be contacted within 48 hours upon receipt of this document to confirm attendance and receive further information about enrollment.  For immediate assistance email: mallen@yccd.edu.

All new students wanting a course must go to the main Yuba College website and "apply now" to create a student account.  Past students must also update account. Questions regarding this process can be directed to Kerry Pope at 530-741-6920.

Parking decals will not be invoiced.  Once an account is established with Yuba College, student may contact Wendy Duck at 530-741-6724

Material/Duplicating/EVOC are separate fees and collected by A.J. Staff.  These fees (if applicable) are separate from the college registration fees (units, parking, student service fee)and will be invoiced by A.J. Staff. Non-affiliated students must pay the applicable fees prior to start date of course unless told otherwise. Please refer to the course requirement list for A.J. expenses collected by staff.